Submit the following online form - or - you can download a copy to fill out at your leisure

Please help us in our efforts to expedite the referral process by providing as much of the following information about your client/patient as possible. We would also welcome more in-depth documents or summaries, whether formal or informal (e.g. medical, psychological or other reports).

This patient is being referred for:

Exposure Program Driver Competency Assessment

Client Information

Date of Birth:
Postal Code:
Driver's License
Diagnosis / reason for referral
Onset / MVC date

Client Medical History

  Please select Yes, No, or Unknown. If yes, please describe.

Will this client present with:
Visual impairments? Yes No Unknown
Auditory impairments? Yes No Unknown
Cognitive impairments? Yes No Unknown
Orthopedic impairments? Yes No Unknown
Other physical or psychological concerns Yes No Unknown
Has this client suffered from previous traumas that we should know about?
Is this client taking medications that could affect safe motor-vehicle operation? Please list:
Do you have any other concerns for your patient in completing an in-home assessment, on-road assessment, or in entering into a desensitization program as a driver, passenger, or pedestrian?

Insurance Information

Insurance Company Name:
Street Address:
City, Province, Postal Code:
Insurance Adjuster's Name:
Phone Number:
Fax Number:
Claim Number:
Policy Number:

Referrer Information

Referring Agency Name:
Street Address:
City, Province, Postal Code:
Referring Agent Name (title + designation):
Phone Number:
Fax Number: